# WAGNER FAMILY DENTAL

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1104209790
- **Authorized official:** DR. BRIAN M. WAGNER DDS (OWNER)
- **Authorized official phone:** (812) 482-4347

## Contact information

- **Practice address:** 4115 MANNHEIM RD, JASPER, IN 47546-2964
- **Practice address phone:** (812) 482-4347
- **Mailing address:** PO BOX 712, JASPER, IN 47547-0712
- **Mailing address phone:** (812) 482-4347

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 122300000X | Dentist | 12010568A | IN | Yes |

## Other

- **Enumeration date:** 07/01/2015
- **Last updated:** 07/01/2015